P01_QASP Caregiver Training Program - Final (Approved) Copy 1.docx

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Caregiver Support Program Training

The contract scope will encompass training and coaching of caregivers at multiple levels within the caregiver program. This contract encompasses delivery of multiple distinct training programs with one (1) access point for referral. This encompasses National Caregiver Training Program (known as core curriculum), Spanish Delivered Self-Care courses, and Spanish Translation for Peer Mentoring Calls.

Issued: TBD i

TABLE OF CONTENTS

QUALITY ASSURANCE SURVEILLANCE PLAN

(QASP)

INTRODUCTION

This quality assurance surveillance plan (QASP) is pursuant to the requirements listed in the performance work statement (PWS) entitled Caregiver Support Program Training. This plan sets forth the procedures and guidelines the Veterans Health Administration (VHA) National Caregiver Support Program (CSP) will use in ensuring the required performance standards or services levels are achieved by the Contractor.

Purpose The purpose of the QASP is to describe the systematic methods used to monitor performance, identify the required documentation, and the resources to be employed. The QASP provides a means for evaluating whether the Contractor is meeting the performance standards identified in the PWS and the Contractor’s quality control plan (QCP), and to ensure that the government pays for the quality of services received.

This QASP defines the roles and responsibilities of all members of the integrated project team (IPT), identifies the performance objectives, defines the methodologies used to monitor and evaluate the Contractor’s performance, describes quality assurance documentation requirements, and describes the analysis of quality assurance monitoring results.

Performance Management Approach Performance management rests on developing a capability to review and analyze information generated through performance assessment. The ability to make decisions based on the analysis of performance data is the cornerstone of performance management; this analysis yields information that indicates whether expected outcomes for the project are being achieved by the Contractor. The PWS structures the acquisition around “what” service or quality level is required, as opposed to “how” the Contractor should perform the work (i.e., results, not compliance). This QASP will define the performance management approach taken by the Caregiver Support Program to monitor and manage the Contractor’s performance to ensure the expected outcomes or performance objectives communicated in the PWS are achieved.

Performance management represents a significant shift from the more traditional quality assurance (QA) concepts in several ways. Performance management focuses on assessing whether outcomes are being achieved and to what extent. This approach migrates away from scrutiny of compliance with the processes and practices used to achieve the outcome. A performance-based approach enables the Contractor to play a large role in how the work is performed, as long as the proposed processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the Contractor flexibility to continuously improve and innovate over the course of the contract as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

Performance Management Strategy The Contractor is responsible for the quality of all work performed. The Contractor measures that quality through the Contractor’s own quality control program (QCP). Quality Control (QC) is work output, not workers, and therefore includes all work performed under this contract regardless of whether the work is performed by Contractor employees or by subcontractors. The Contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The Contractor will develop and implement a performance management system with processes to assess and report its performance to the designated government representative(s): the CSP program manager (PM) and/or the contracting officer's representative (COR). The Contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS.

1.3.2 The government representative(s) will monitor performance and review performance reports furnished by the Contractor to determine how the Contractor is performing against communicated performance objectives. The Contractor will be responsible for making required changes in the processes and practices to ensure performance is managed effectively.

ROLES AND RESPONSIBILITIES

The Contracting Officer The contracting officer (CO) is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the contracting officer's representative (COR) and/or the program manager (PM) and the Contractor.

The Contracting Officer’s Technical Representative The contracting officer’s representative (COR) is designated in writing by the CO to act as his or her authorized representative to assist in administering a contract. COR limitations are contained in the written appointment letter. The COR is responsible for technical administration of the project and ensures proper government surveillance of the Contractor’s performance. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf. Any changes that the Contractor deems may affect contract price, terms, or conditions shall be referred to the CO for action. The COR will have the responsibility for completing QA monitoring to document the inspection and evaluation of the Contractor’s work performance. Government surveillance may occur under the inspection of services clause for any service relating to the contract.

IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

The required performance standards and/or quality levels are included in the PWS and in Attachment 1, “Performance Requirements Summary.”

METHODOLOGIES TO MONITOR PERFORMANCE

Surveillance Techniques In an effort to minimize the performance management burden, simplified surveillance methods shall be used by the government to evaluate Contractor performance when appropriate. The primary methods of surveillance are:

· Random monitoring, which shall be performed by the COR designated inspector.

· Periodic Inspection –COR will typically perform a periodic inspection monthly.

Customer Feedback The Contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction. Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

Customer complaints, to be considered valid, must be submitted in writing with a detailed description of the complaint, they must be signed, and must be forwarded to the PM/COR. The PM/COR will accept those customer complaints and start the investigation process using the Quality Assurance Monitoring Form. It’s important to identify that the customer always has the option to communicate complaints directly to the PM/COR as opposed to the Contractor.

Customer feedback may also be obtained and recorded from either the results of the customer satisfaction surveys or from random customer complaints.

Acceptable Quality Levels The acceptable quality levels (AQLs) included in Attachment 1, Performance Requirements Summary Table, for Contractor performance are structured to allow the Contractor to manage how the work is performed while providing negative incentives for performance shortfalls. For certain critical activities such as those involving customer concerns, the desired performance level is established as “Acceptable”. Other levels of performance are keyed to the relative importance of the task to the overall mission performance for caregiver support training services.

QUALITY ASSURANCE DOCUMENTATION

The Performance Management Feedback Loop The performance management feedback loop begins with the communication of expected outcomes. Performance standards are expressed in the PWS and are assessed using the performance monitoring techniques shown in Attachment 1.

Monitoring Forms The government’s QA surveillance, accomplished by the COR, will be reported using the monitoring forms in Attachments 2 where appropriate. The forms, when completed, will document the government’s assessment of the Contractor’s performance under the contract to ensure that the required results quality levels are being achieved.

ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

Determining Performance Government shall use the monitoring methods cited to determine whether the performance standards/service levels/AQLs have been met. If the Contractor has not met the minimum requirements, it may be asked to develop a corrective action plan to show how and by what date it intends to bring performance up to the required levels.

Reporting Upon completion of periodic reviews, the PM/COR will prepare a written report and it will be maintained in the COR file summarizing the overall results of the quality assurance surveillance of the Contractor’s performance. It will enable the government to demonstrate whether the Contractor is meeting the stated objectives and/or performance standards, including cost/technical/scheduling objectives.

Reviews and Resolution The PM/COR may require the Contractor’s project manager, or a designated alternate, to meet with the CO, COR, or PM, as deemed necessary, to discuss performance evaluation. The CO will define a frequency of in-depth reviews with the Contractor, including appropriate self-assessments by the Contractor; however, if the need arises, the Contractor will meet with the PM/COR as often as required or per the Contractor’s request. The agenda of the reviews may include:

· Monthly performance assessment data and trend analysis

· Issues and concerns of both parties

· Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis

· Recommendations for improved efficiency and/or effectiveness

· Customer service or process flow issues arising from/identified through the performance monitoring processes

The PM/COR must coordinate and communicate with the Contractor to resolve issues and concerns regarding marginal or unacceptable performance.

The PM/COR and the Contractor should jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels should be clearly documented.

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

Required Services (Tasks) Performance Standards Acceptable Quality Levels Methods of Surveillance

Submit Weekly, Monthly and Annual reports (PWS IV. Specific Tasks and Tasks)

Administer quality control program including subcontractor management in accordance with QCP

Customer Service

Submit (encrypted format) monthly roster of completed training with Name, CARMA ID and completed training dates for verification of eligibility and training Reports submitted accurately depict current status

Contractor is in compliance with their QCP

Contractor alerts the PM/COR/CO of new complaints in writing within 24 hours and either resolves (or provides explanation) for all complaints

Reports accurately depict eligible participants receiving and completing the training Acceptable - Contractor delivery of products and/or services successfully met all Contract requirement. Problems that are encountered are minor and are resolved in a satisfactory manner determined acceptable by VA.

File reviews, periodic inspections, and random, observations, customer complaints

File reviews, periodic inspections, and random, observations, customer complaints

Observations, Customer complaints, and file reviews

File reviews, periodic inspections of monthly rosters and random observations

Acceptable: All Quality levels meet requirements. Risk of unsuccessful performance is low.

Marginal: Rating has one or more weaknesses which are not offset by Acceptable rating. Risk of unsuccessful performance is high.

Unacceptable: Quality level does not meet requirements. Corrective action plan needed.

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE

MONITORING FORM

SERVICE or STANDARD:

SURVEY PERIOD: Random and/or Periodic SURVEILLANCE METHOD (Check):

Random Sampling 100% Inspection Periodic Inspection Customer Complaint LEVEL OF SURVEILLANCE (Check):

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

Narrative of Performance During Survey Period:

PREPARED BY: ___________________________________ DATE: _________________